Patient Portal

Caregiver Authorization Form

After completing this form, hit the 'Continue' button and you will be prompted to print the form to be submitted. Sign in the designated area and then mail or fax it to the address listed on the printed form. If you do not have printing capabilities, please do not proceed.

Caregiver

Please indicate your relationship to the patient by selecting one of the following:*

Son
Daughter
Spouse
Other

If Other, please specify:*

Caregiver Name:*Caregiver Address Same as Patient?Street:*City:*State:*

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Dist of Columbia

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Zip:*

Caregiver Medical Record Organization:

Select...

Geisinger

CommunityCare

Susquehanna Valley Medical Specialties

Caregiver Medical Record #: Caregiver Date of Birth:* Email (to be notified when new messages about the patient's care are sent to MyChart(Powered by Geisinger)):* All Former Name(s) - e.g. Former Married or Maiden Name:

Do you (caregiver) have an active MyChart (Powered by Geisinger) account?
Yes
No
Unsure

Is this request to access the patient's MyChart Bedside information while the patient is admitted to the hospital?*
Yes
No